If you asked the average physician whether it was more important to be able to communicate with hospitals or physicians within the community to whom they refer patients, my guess is that the vast majority would choose physician-to-physician communication. The most recent podcast published on CanadianEMR was a frank discussion with Dr. Mark Dermer entitled Should Physicians be Forced to Adopt EMRs? In this podcast, Dr. Dermer makes the point that physician-to-physician communication has never been part of the national IT strategy. This is evidenced by the fact that EMR-to-EMR interoperability standards have never been clearly defined. This critical limitation is reducing growth of the market and adoption of EMRs.

Why is it so important? Most community-based physicians (where 80% of the care is delivered) spend a significant part of their day referring patients or responding to consultation requests. As a result, even with the best EMRs currently available, these referrals are created digitally and either printed or faxed to the receiving physician's office. There they are printed or received as fax/scanned documents into the EMR (if one is used) and when a report is created, the whole process is repeated as these reports are digitized, printed, and transmitted all over again. What a waste of time and energy.

How could we have missed this fundamental requirement for an EMR? The ability for providers of care to communicate and collaborate with one another!

Some may argue that it is too complex having EMRs communicating with one another directly through point-to-point communication. In this regard, I agree. However, there are many intermediary third-party information exchange providers who specialize in taking data from one system and translating it into a format that can be received by any other system to which it connects. These information exchanges are widely available and in each U.S. state are being deployed to handle exactly these issues.

Physicians communicate with and refer to a wide number of clinicians and ancillary care providers. An information exchange should be able to handle all of these communications needs and options. Perhaps at the beginning, a smaller number of connections are provided, but over time the use of the information exchange needs to become ubiquitous such that sharing of information is not an issue.

We should limit the development of proprietary provincial information exchange capabilities in favour of universal messaging standards that allow vendors of EMRs to build once and use many times. One can only hope that common sense prevails.

Healthcare is extremely political in Canada! No big surprise to anyone who has been involved in health administration or planning, perhaps because healthcare is viewed as a national right under the Canada Health Act. Any political party that attempts wide scale change to the healthcare system is courting political disaster — change will be challenging and will provide ample cannon fodder for any opposition party. As a result, we tend to make minor incremental changes to the system.

Unfortunately health information technology has been dragged into the politics of healthcare. Even though the need for health information modernization is a foundational requirement in order for Canada to have a high performing healthcare system, health IT is frequently dragged into physician fee negotiations or suffers embarrassment at the hands of opposition health critics (as we have seen with a number of eHealth scandals that have been prominent in the media).

But how does one build core infrastructure if the requirements are so sensitive to political whim? Imagine the national road system being managed in the same way. Every three to four years, negotiations would take place between those who use the roads and the government to determine whether they would support financing for the next four years. If negotiations went badly, both parties would just walk away from the table. Sounds pretty ridiculous, right? However that is exactly what happens with healthcare and — more to the point — health information technology.

Is it possible to separate core foundational requirements from those that are politically driven? Canada Health Infoway was an attempt to create an entity to do just that, but has fallen short of the goal. Provided with funding to support provincial programs in their adoption of health IT, Infoway has been successful with some provinces, but not all. There was a general underestimation of the difficulty in working with certain provinces because of their perceived unique requirements and pre-existing investment in infrastructure such as hospital information systems.

A single, government driven healthcare system would seem to be a perfect setting to implement health IT; however, that has certainly not been the case. We have a fragmented national EMR strategy with adoption stalled at the 50% mark in most of the major provincial EMR programs. We have no standards for data exchange between EMRs, and we have resistant provinces doing what they feel necessary with limited healthcare budgets. Expect government/physician negotiations to become much more confrontational as many of the provincial agreements expire over the next 2–3 years.

What needs to be done to move health IT forward? Is it possible in Canada to de-politicize EMR/EHR foundational infrastructure and other health IT initiatives so that the foundation can be properly built?

One of the trends taking place internationally is a concerted effort by governments to control the cost of medications. In 2010, $31.1 Billion out of a total $192 Billion was spent on drugs in Canada (16.3%). In contrast, $26.3 Billion was spent on physician services — 13.7% of total health expenditure (Source: Canadian Institute for Health Information). More is spent on drugs than physician services and this number is accelerating as new advances are made and more costly treatments become available.

Is this the fault of money hungry pharmaceutical companies? What happens when genomically matched custom drugs become widely available? How much of the cost is due to inappropriate or overuse of medications or poor administration practices? The pharmaceutical industry is designed to innovate, advance treatments, and make money. It is a highly competitive industry and when blockbuster drugs are identified, companies are hugely profitable.

So, what is the appropriate role of pharma when it comes to Electronic Medical Records? I have seen little written about this subject and am interested to hear your feedback. Some would say that the pharmaceutical industry should stay out of your medical records completely. Forays into computerization in doctor’s offices have had some disastrous results. In the early 1990s a pharmaceutical company gave computers to physicians who committed to place a minimum of 10 patients on a specific drug and report the results (via modem) to a research group. This brought a swift response and contributed to the tightening up of rules governing appropriate relationships between physicians and the pharmaceutical industry. Over the years, these rules have become more stringent and are governed by a code of ethics developed by Rx&D (Canada’s Research Based Pharmaceutical Companies) and the Canadian Medical Association (Guidelines for Physicians in Interactions with Industry).

In addition, physicians are bound by a code of conduct overseen by their provincial licensing bodies. However the area is complex and pharmaceutical companies have been very tentative in terms of any involvement directly with EMRs. Before you raise your hands and shout hurrah, think for a moment of your paper records. How many physicians accept free reams of paper for clinical note-keeping with pharmaceutical product advertising across the footer of each sheet distributed by a company called Formedic? I used them in my paper charts as do tens of thousands of physicians across Canada and the United States. They are cost-effective and the advertising becomes invisible after a while. This is equivalent to bringing up a progress note in your EMR and having a pharma ad displayed alongside every note. I doubt that many physicians would accept this level of intrusion into their EMRs; however, it is standard practice in the holy grail, the paper medical chart. Interesting anomaly!

The majority of medical journals could not exist without pharmaceutical advertising. In addition, as much as we complain about the cost of drugs, we would not have seen proton pump inhibitors, SSRIs, or anti-virals without the huge investment in research made by pharma.

Consider the following scenario:

An endochrinologist in a local community approaches a district manager from a pharma company with a diabetes drug and requests an unrestricted grant for funding in order to develop a disease management application that will allow patients to document a number of disease monitoring metrics and report them back to their physician using a mobile phone and the Internet. This seems like a good idea and the funding is provided. After passing ethics reviews, the project kicks off and achieves limited success in the local community. However it is not widely adopted because there are competing projects developed by the hospital and the provincial primary care program and this just seems like duplication (even though the lead physician makes a good case for the uniqueness of his specific project). And the results are good. There is clear evidence that disease outcomes are improving for patients in the local community. However the project never receives wide support and after much frustration, it is shut down. Another example of good intention misdirected.

This scenario is more common than one might believe. The inability to scale projects beyond a local geography as well as the conflicts with policy and health IT programs are generally the death knell.

Should pharma support these types of projects? What are the rules and guidelines by which these types of ethical support should be governed? As EMRs become more common and the ability to e-Prescribe becomes commonplace, what is the role of pharma and what is appropriate in terms of supporting or being involved with programs to improve prescribing practices and the management of medications?

From time to time, one reads about security breaches as a result of a computer being stolen containing patients’ personal health information or breaches as a result of a network being hacked (as occurred recently to Sony’s online gaming community). However, as more information is stored in “the Cloud”, how secure is that data and how worried should we be about breaches?

“At Software Advice, we speak on the phone every day with physicians who are researching electronic health records (EHR) software. We commonly hear that they’re afraid to switch to a system that puts their health records “in the cloud.” Their fear is that patient records will be out there on the Interweb, just waiting to be hacked. We’ve written about this misconception plenty and even touched on the double-standard of using web banking while eschewing cloud-based EHRs. Just a hunch, but I bet more hackers want my credit card information than my HDL/LDL ratio.

Now, the US Department of Health and Human Services (HHS) is disclosing on its website all health record security breaches that affect more than 500 people. This provides a trove of data to back up our assertions that cloud-computing is safe. Of course, it’s all relative.”

Michael has published some interesting graphs and tables summarizing the top causes of security breaches. Although Canada is somewhat different in structure, I believe the breakdown would be quite similar.

Have you or someone you know experienced a security breach? Provide your thoughts and feedback by clicking on the “Comments” link below.